Obverse

My support for a single-payer system of health care has been made clear. On the other hand, as I've also said, strongly, I have no illusions about the potential for running good doctors out of the business, since, so far, the only major cuts in health care costs have come via lowering reimbursement to doctors and hospitals. The dangers of continuing that process are obvious, and are taking place already. To some extent, I'm an example, as I had to work harder and harder -- to the point of irreversible burnout -- to maintain income. Beyond the financial there was both a physical and psychological toll: at no point was there recognition of the superior care I was delivering -- it simply didn't matter. Each year, reimbursement declined irrespective of my results, my costs, my efforts. (Trust me on the "superior care" claim. Or if not, believe there are docs doing a better job than others, with nothing to show for it.)

It's another in a line of emails from The American College Of Surgeons, of which I'm a Fellow, that provokes this post. It refers to the 21.2% cut (.2? That's like the offer from the car salesman, down to the penny, as if it's the best they can do, based on extremely accurate calculation) in Medicare payments to doctors, beginning Monday. The Senate, as usual, failed to act after the House did, in fact, put the cut on hold. Said the letter, written by a guy I trained with,

"...Last night, the Senate failed to pass a series of extensions that included a temporary halt to the 21.2 percent cut in Medicare physician payments. As a result, the cut will go into effect on Monday, March 1st. Earlier yesterday, the House successfully passed the extensions package by voice vote that would have maintained the current conversion factor of $36.0666 through March 28th. However, with Congress currently adjourned, the Senate will have to again attempt to pass an extensions package sometime next week. The length of the temporary extension is unclear at this point, but we do expect it to provide only short-term relief from the 21.2 percent cut and be retroactive to March 1st..."

In my former clinic it came to the point that we were losing money on Medicare patients. At the moment the only Medicare plans they accept are "Medicare Advantage," a program about to be cut, it would appear. A program that now covers me.

There's an end-point. In my area there are several doctors who do not accept Medicare at all. They'll see those patients, but only on the condition that they accept direct (and full) billing, and fight on their own for Medicare payment. In New York City, as I understand it, there are docs who don't even accept private insurance for any patient, demanding the same "deal" as I just described.

Every time I've posted on physician reimbursement, especially on Surgeonsblog which people actually read in significant numbers, I got a predictable number of nasty comments saying doctors are overpaid and that they underperform (except to the extent that they are considered able, evidently, to engage in anatomically impossible sexual acts). But, as I've also argued, in many ways doctors are quite similar to actual humans. Altruism, unrewarded, is not a good business plan, especially when we're talking livelihood. Taking 21.2% out of payment that's already inadequate isn't tenable. (What's "adequate?" Well, how about, as a minimum, covering overhead?)

There was a time when many doctors made too much money for too little work. Some still do. But generally, it's no longer true; especially if you look at Medicare and Medicaid reimbursement. I'm fine -- and I always was -- with the idea that we need to sacrifice something to care for the less well-off. But I'm not fine with the idea that it's only health care providers who sacrifice, that the only thing politicians have the balls to do -- and the only thing voters have no problem with, sacrifice-wise -- is cutting payments. And yet, there we are. [Need it be said again?: this is in large part a direct legacy of Ronald Reagan's aptly named, by his later vice-president, "voodoo economics." For generations, with a brief departure in the 90's, we've been fed the idea that we can have whatever we want and not pay for it. That belief, despite the recent unsubtle evidence to the contrary, has a half-life longer than Pu-239. (At least the Russians moved Stalin out of Red Square eventually. Republicans keep digging up Ronnie and trying to reanimate him, completely ignoring his disastrous legacy of economic falsehood. But I digress.)]

So that's the downside of single-payer: limited ability of providers to influence a rational payment structure. But, really, it isn't much better with private insurers: they've cut payments by about two-thirds since I began practice, and providers have rarely been able to resist. At least, with single payer, there'd be comparatively more money left in the system, some of which might, conceivably, make it to providers.

And there's no reason why enabling legislation couldn't include a sensible means of establishing workable reimbursement. Other than the fact that it would have to happen here.

Meanwhile, even for a guy no longer in practice, it's easy to predict that if these cuts happen, there will be hell to pay. Oh well: at least someone will get paid.